Waiting List

Apply for Pinehaven

Add a Child

Please use this form to apply to have a child under your care be added to our waiting list.


About This Child

Please tell us everything you can about this child for whom you are applying.
The Individualized Educational Plan (IEP) is a plan or program developed to ensure that a child who has a disability identified under the law and is attending an elementary or secondary educational institution receives specialized instruction and related services.
Please give a description of your child's problems and include all relevant concerns including drug/alcohol/tobacco use, whether he or she is sexually active, whether there are any charges pending (or convictions) or any other legal considerations, any history of violent behavior, any history of sexual or physical abuse (either received or inflicted) and, if the child is a girl, state whether she is pregnant.

Contact Info

Please enter your contact information below.
Please enter your mailing address for our records.

Pinehaven: Providing a Second Chance

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